The Medical Benefits Abroad (MBA) Claim Application Form of Cigna Health and Life Insurance Company is as follows:

Cigna MBA Claim Form




Few Things to be mentioned in the Form

Section A – Employee/Patient and Travel Information

Date(s) of service, earliest date if multiple (MM/DD/YYYY)

Country where services were rendered

Diagnosis/Reason for treatment

Travel Dates: (required for claim submission)

Departure from home country on/Return to home country on

Employer Name/Policy/Group Number

Employee’s Name (Last)/Patient’s Name (Last)

Employee’s Name (First):/Patient’s Name (First)

Employee’s Date of birth (MM/DD/YYYY)/Patient’s Date of Birth (MM/DD/YYYY)

Employee’s Mailing Address

City: State: Postal/Zip Code